Medical Insurance Form

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TRAVEL INSURANCE INFO

Full Name written exactly as on passport *

First

Last

Have you taken out Medical Travel Insurance for your current trip in South Africa

Yes
No

Please insure your Travel Insurance covers you for Riding Motorcycles over 300cc in a Foreign Country

of Name any

Name of Travel Insurance Provider

Emergency Phone Number of Travel Insurance

Policy Reference Number

Please list any Medical problems or Allergys that you have

Please list any Medications that you are taking

Next of Kin Contact Information

Name of Next of Kin (Family or friend) *

First

Last

Contact Number of Next of Kin *

Relationship to you?

Comments:

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info1@samatours.co.za

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Medical Insurance Form